Journal of Psychological Abnormalities
, J Psychol Abnorm Child 2014, 3:4
in Children
Case Report
Specific Features of Child Psychiatry in a Multidisciplinary Hospital,
Morocco
Abdeslam Benali*, Fadoua Oueriagli, Wydad Hikmat, Amine Laffinti, Imane Adali, Fatiha Manoudi1 and Fatima Asri
Research Team For Mental Health, University Cadi Ayyad, Marrakesh, Morocco
Abstract
Modern child psychiatry responds to increasing demands of confused parents and sometimes of perplex teachers.
The objective of this kind of work is to illustrate the particularities of child psychiatry in a multidisciplinary hospital,
defining the major fields of application of child psychiatry liaison and the difficulties related to this activity. This article
illustrates the importance of identification and prevention of the suffering children, privileging a close collaboration
between different actors, respecting the role of each other.
Keywords: Child psychiatry; Multidisciplinary hospital; Network
Introduction
The concept of child psychiatry is nowadays well integrated by health
professionals. In fact, there has been a significant increase in demand for
medical care [1]. Therefore a reflection articulating the psyche and the
soma is required in order to afford a global approach and treatment [2].
The main objective of our work is to illustrate the particularities of child
psychiatry in a multidisciplinary hospital, defining the major fields of
application and difficulties related to this activity. We discuss this work
in three clinical cases that seem to reflect the vast majority of patients
that we receive as part of the liaison psychiatry, child psychiatrist is an
integral part of pediatric teams. Noted in this work that patient consent
was obtained. All parents gave their consent to include the clinical
history with their children.
The historical aspects
Liaison psychiatry has been developed respectively in USA and in
European countries between 1930s and 1970s. The first child hospitals
played initially a social role. Their main aim was to fight off poverty,
and then they gradually became therapeutic institutions. At first, it
did not seem particularly useful to have a child psychiatry team in
pediatric services. It is through the intermediary of psychoanalysis that
the interest of the psyche made his entrance in the pediatric hospitals;
child and adolescent psychiatry will adopt later other common theories
to child development, and specific therapeutic approaches from adult
psychiatry. This will gradually lead to the development of a bio-psycho-
social model taking into account: neurobiological, social, environmental
and psychological factors.
Clinical Illustrations
Suicide attempt case
A 17-year senior high school teenager was sent by his physician for
a psychiatric evaluation, because he was lost of all interest and pleasure
This teenager tried to commit suicide 8 days before by taking hypnotic
pills. During the interview, he was tense, with frozen facial expression,
he had a great difficulty expressing himself, seemed lost in his thoughts
and the dialogue was hard at first.
We understood later that our patient just moved from Casablanca
and integrated a new high school in the city of Dakhla in the south
of Morocco; he also said that he was hopeless, disappointed because
he got a bad grade for the very first time of his life. He added that he
had many suicidal scenarios in mind before talking those pills. This
suicide attempt is a real desire for death and intentionality is strong. The
suicidal act was planned and premeditated. We have not found personal
J Psychol Abnorm Child
ISSN: 2329-9525 JPAC, an open access journal
Benali et al.
http://dx.doi.org/10.4172/2329-9525.1000132
Open Access
psychiatric history. However, his mother was treated for depression for
several years.
Meanwhile, his father who accompanied him to the hospital assured
us that his son has always been quiet, studious and serious... He
believed that this was probably just an accident. Biographical elements
are very rich: the parents are simple people, both retired. They have no
sense for entertainment. Their affection toward their children was very
limited if not absent. The main conversation ever engaged was about
the assets. He always felt furious but has never expressed it openly. He
feared to hurt his parents feelings.
Our patient was kind of a loner, never had a girlfriend and was not
able to make simple choices such as choosing his own hair cut. The
suicide attempt of this brilliant schoolboy was the final spot of a long
neurotic distortion in his development. The rather ordinary triggering
motive: the bad grade was only the straw that broke the camels back. The
invisible and the most important part of the iceberg is represented by : his
low self esteem, his history of depression with a weakened ego, hidden
anger, as well as the conflictual relationship with his demanding parents.
He felt trapped into their old fashioned lifestyle, which prevented
him from having a fulfilled life, the only way to overcome this was his
rebellious behavior (reckless driving, speeding ) considered by our
team as suicidal equivalents.
The aggressiveness of the teenager is diverted from its normal
outlets. Instead of using it to develop his own personality, to enhance
his autonomy, he turned it against himself. The unbearable isolation
from the contemporary group, as well as the emotional distancing from
his parents drowned him in an awful feeling of loneliness. Emotional
relationship with parents offers him no support; there is no more access
to peers of his age. The only escape he had was his imagination, he was
always picturing running away and using drugs, while in reality he
remained bound by his guilt. The tension increases and the situation
become increasingly hopeless.
*Corresponding author: Abdeslam Benali, Research Team For Mental Health,
University Cadi Ayyad, Marrakesh, Morocco, Tel: 00212 661402302; E-mail:
abdes.benali@yahoo.fr
Received March 28, 2014; Accepted November 07, 2014; Published November
14, 2014
Citation: Benali A, Oueriagli F, Hikmat W, Laffinti A, Adali I, et al. (2014) Specific
Features of Child Psychiatry in a Multidisciplinary Hospital, Morocco. J Psychol
Abnorm Child 3: 132. doi:10.4172/2329-9525.1000132
Copyright: 2014 Benali A, et al. This is an open-access article distributed under
the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and
source are credited.
Volume 3 Issue 4 1000132
Citation: Benali A, Oueriagli F, Hikmat W, Laffinti A, Adali I, et al. (2014) Specific Features of Child Psychiatry in a Multidisciplinary Hospital, Morocco.
J Psychol Abnorm Child 3: 132. doi:10.4172/2329-9525.1000132
Nothing in the behavior of the patient indicates the imminent
suicidal act. His decision to end his life was not perceived neither by his
classmates nor his parents, furthermore the Suicidal equivalents were
falsely interpreted as madness. The parents didnt realize that their kid
was living a crisis; they didnt notice the change in his mood, meanwhile
he was obsessed with death. Their teachers, classmates were devastated
and saddened by his suicide attempt.
After being diagnosed, our patient received a prescription of an
antidepressant (50 mg of Sertraline per day for a period of 12 months),
as well as a regular psychotherapeutic work (1 session per week). The
results were very good, and the patient resumed his studies and was
very comfortable to come to every planned session.
Both parents have received psychological help, in the form of
couples therapy.
Childhood depression case
A 10-year-old boy was sent by his pediatrician to the 4th Military
Hospital for a psychiatric consultation. In his medical record, the
physician related that he always had digestive problems. Many tests
were run and were all negative.
The patient is the oldest of his siblings, he was a desired child, and
his parents got divorced after the birth of his little sister, 5 years ago. He
had a normal psychomotor development, and an ordinary schooling
path. Until the day his mother started receiving phone calls from school
complaining about his excessive absenteeism. It was hard for him to
wake up, and once at school he had nausea and vomiting which forced
him to return back home immediately, he also suffered from permanent
headache and abdominal pain. The symptoms became increasingly
frequent and disabling and he became aggressive and constantly
threatening to commit suicide.
We were confronted to a child with diverse and varied symptoms,
school decline, access of anger and self mutilation. We gave him
occasionally levomepromazine to manage his insomnia (15-20 mg per
day) administered orally at bedtime.
The psychotherapeutic work aimed essentially to point and
addresses the family dynamics. The parents were isolated from the
world, the mother was often depressed and the father was a violent
alcoholic. The child gradually integrated the link between his physical
disorders and the conflict within the parental couple. The follow-up
has created a space for dialogue for the young patient, and therefore an
access to mental health care.
It allowed us also to treat the depressed mother. Psychological
support for the couple has been advocated. These results were significant.
The evolution after 8 months was relatively good, nevertheless we
observed the emergence of an OCD justifying the introduction of an
antidepressant (fluoxetine 20 mg per day), which was effective and well
tolerated, with as subsequent project, C.B.T sessions.
School failure case
This is a young 15-year-old girl sent to us directly by her teacher
who noticed various behavioral problems for a psychiatric consultation.
Her medical records showed that her psychomotor development was
perfect. However she was diagnosed with celiac disease and had an
accident recently with multiples and severe head trauma.
The mother claims that her daughters behavior has changed ever
since the accident. But for her it was normal with the adolescence
crisis, which is intensified by the fathers absence.
J Psychol Abnorm Child
ISSN: 2329-9525 JPAC, an open access journal
Page 2 of 4
She became aggressive even toward her teacher, turbulent and
sometimes insomniac. She also finds it difficult to be attentive during
the class. This causes her enormous difficulties in learning, reading and
writing. These difficulties appear to be related to personality changes
and major neurocognitive disorders. These problems appeared a few
weeks after the highway accident, followed by a secondary enuresis and
severe headaches. She seems sensitive to the therapeutic relationship;
her gestures and mimicry reflect sadness and apathy. She points out to
her problem to integrate the group at school, fearing at the same time
to loose her future.
Due to the lack of means and specialized personnel to introduce
this patient in the hospital for a certain time, we opted to grant her
short and frequent psychiatric sessions. The psychomotor test reveals
big problems, both at the level of corporal scheme and temporal-spatial
organization. Neurocognitive evaluation shows the attention disorders.
The attention is selective and fluctuating without instability or
impulsivity. Memory is somehow more visual than aural. The memory
of work is very disturbed.
There are also language problems concerning her way of
expressions. The field of gnosis, praxis and graph-motor is preserved.
We were able to start a treatment (Carbamazepine: 400 mg per day)
and psychotherapy. Working with a psychomotor and speech therapist
at a rate of twice a week Helped in the management of neurocognitive
disorders. The evolution was marked by a significant decrease in
behavior problems. But she remained in great resentment against the
school board. Family brought up the idea of moving
to Casablanca, to
enable the girl to continue her education in another institution.
Discussion
This work allowed us to seize some particularities of the child
psychiatric practice within a multidisciplinary hospital. It seems to us
that we can indeed, through clinical samples, illustrate the different
aspects of child psychiatry, and identify some pitfalls and difficulties
related to this activity. The first patient illustrates a case of emergency,
which corresponds to the unscheduled intervention demands. A
concept that refers to three types of situations to which a psychiatrist is
required to intervene without delay:
1 - The immediate emergency, emergencies that involve a quick
intervention. Those include teenagers and children over 13 years old
[3-5]. Those are especially suicide attempts, acute psychosis, anorexia,
bulimia, post-traumatic-stress-disorder, neuropsychiatric disorders
related to organic diseases (epilepsy, metabolic disorders...).
2 Interventions without delay, often require intervention during
the day. Those correspond to our practice to seek medical advice
sometime before the patient can be discharged from the hospital.
3 New emergencies, a situation as described by the authors
that corresponds to demanding assistance from other practitioners in
diagnostic evaluation, therapeutic or preventive adjustment.
We often run into difficulties within the child psychiatry
practice scope. Particularly when the management of the emergency
situation is inappropriate. This problem makes doctors enter ether
in misunderstanding or conflict. Therefore, the ideal is to receive
the request from these practitioners and provide answers as soon as
possible [6,7]. We note also that the anxiety and the overwhelming
emotions of parents in the context of the emergency affect considerably
the child psychiatric diagnosis [8]. The anxiety disorders are considered
as the most frequent. The communication with the physician becomes
sometimes difficult for the psychiatrist. He must deal with a series of
Volume 3 Issue 4 1000132
Citation: Benali A, Oueriagli F, Hikmat W, Laffinti A, Adali I, et al. (2014) Specific Features of Child Psychiatry in a Multidisciplinary Hospital, Morocco.
J Psychol Abnorm Child 3: 132. doi:10.4172/2329-9525.1000132
profiles facing a practitioner who confesses his incapability and gives
up in front of the psychological suffering of the patient [9,10]. For this
reason, the main task of child psychiatry remains in establishing links
between many partners to make good use of the available resources by
developing a real functioning network.
The second case reflects the immense majority of our clients. These
are patients with functional symptoms. However, the problem keeps
persisting despite all the medical investigations, which prove that the
patient is free from any organic disease. Even if there is a possible
genuine physical disorder, the latter can neither account for the nature,
severity of the disorder, nor the distress concerning the subject. These
problems are classified as somatoform disorders in accordance with
the ICD 10. In literature review, recurrent abdominal pain affects
between 8 to 25% of children in the general population and at the same
time it represents 2 to 4% of pediatric consultations. Concerning the
psychiatric level, 70% of patients come from triggering factors (parental
divorce, recent mourning) so these disorders can have an impact on
school assessment [11,12].
The third case shows that school failure is a common reason to
ask for a child psychiatric assessment. Under multiple factors, social,
educational, the parents as well as the school staff when ever they see a
child with schooling problems they prefer to seek a psychiatric advice.
The request for such assistance must be within the framework of a
rigorous medico-psychological approach for a better orientation [13].
This step must take systematically into consideration neurobiological,
psychological and educational factors. These three clinical cases
schematically represent the majority of our patients consulting for child
psychiatry at a multidisciplinary hospital:
1 - Psychiatric emergencies
2 - Somatoform disorders
3 - School failure
4 - Other: detection of severe development disorders, sexual abuse,
psychiatric disorders secondary to organic pathologies.
The size and composition of a child psychiatry team is variable.
Concerning our case, it is a reduced team, by the nature force: it
contains a psychiatrist and a polyvalent nurse. Our intervention as a
team is done in three stages:
1 - The consultation request analysis:
The wording of the request of the consultation influences the quality
of collaboration between practitioners. It must answer two questions:
who is seeking the intervention and in which context? According to
the doctors, the nature of demand is variable. We find that it is scalable
and dynamic. This essentially depends on the different visions of the
disease, childhood and child psychiatry [14,15]. It is essential for the
practitioner to prepare and inform the patient and family about the
child psychiatric consultation, to avoid paradoxical reactions.
2 - The child psychiatry consultation:
The child psychiatry consultation usually takes around 60 minutes.
In most of the cases, we discover that the reason for the consultation
is not the main problem for which he needs a medical intention. The
interview with parents is inevitable; particularly with mothers, because
most of the fathers are soldiers who serve far away from home.
3 - Answers:
After each consultation, the psychiatrist must submit the findings
and proposals to the applicant, the child and parents. This response
J Psychol Abnorm Child
ISSN: 2329-9525 JPAC, an open access journal
Page 3 of 4
must include a clear and precise idea about the psychiatric evaluation,
using a simple and accessible speech as well as therapeutic alternatives.
A child will not talk to the psychiatrist unless he is sure that his
secret is safely kept [16,17]. The relationship between different doctors,
according to Winnicott, doesnt concern only their specialties, but also
the difference in their emotional attitude. The difference related to the
symptom may cause disagreements; in which the recognition from
the part of all the doctors can serve as a reflection of intra-psychic
movement of the jointly taken care patient. This will permit elaborate
constructive relationships with families [8,18,19], and to get to all
aspects of the disease.
Some challenges are specific to child psychiatry, inherent frustrations
to this activity are divers and varied and should be discovered:
- A dissatisfaction that may arise from interventions for patients
who have rarely applied for psychic assistance.
- A great part of activity, which is not directly therapeutic.
- The question of identity and the place of the child psychiatrist.
- The diagnostic uncertainty is a major dimension of medicine
as medical ethics.
- Finally, in equivalence between the increasing demands and the
means available at the child psychiatry.
Conclusion
Modern child psychiatry responds to increasing demands of
confused parents and sometimes of perplex teachers.
Consultation liaison psychiatry is an important way to reach out
to children and adolescents with psychological problems and their
families. There may also be stigma associated with mental illness and
psychological help from a multi-disciplinary team may help assuage the
parents fears as well.
This article illustrates the importance of the identification and
the prevention of the suffering of children, privileging the close
collaboration between different care givers, respecting the role of each
other.
Finally, the intervention of the child psychiatrist, according to
Graber specialist of human, speech and the relationship must not give
up the habit other practitioners to withdraw from the most difficult
questions (child abuse, disclosure of serious diseases to patients,
handicap support, and chronic illness or death).
Contributions of Authors
We confirm that all the authors of the manuscript have read and
agreed to its content, that readily reproducible materials described in
the manuscript will be freely available to any scientist wishing to use
them for non-commercial purposes. Persons listed as authors should
have contributed to the manuscript per the URM criteria for authorship
and contributorship.
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Citation: Benali A, Oueriagli F, Hikmat W, Laffinti A, Adali I, et al. (2014) Specific Features of Child Psychiatry in a Multidisciplinary Hospital, Morocco.
J Psychol Abnorm Child 3: 132. doi:10.4172/2329-9525.1000132
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